1. PROCEED WITH CAUTION performance incentive programs and racial disparities
Alyna Chien MD MS
Marshall Chin MD MPH
Andrew Davis MD
Lawrence Casalino MD PhD
University of Chicago
Pay-for-Performance Summit
Beverly Hilton – February 15, 2007

2. Outline Background / Evidence Impact on racial disparities
Leader perspectives on current programs (or at least not widening them)
Recommendations

3. Performance incentive programs

4. Performance incentive programs
Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes

5. Performance incentive programs
Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes
“Pay-for-performance”  cash

6. Performance incentive programs
Definition. Explicitly link rewards and/or sanctions to performance on specific measures of health care processes and/or outcomes
“Pay-for-performance”  cash
“Public reporting”  reputation

7. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

8. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

9. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

10. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

11. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

12. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

13. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

14. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

15. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

16. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

17. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

18. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

19. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

20. Not all programs are created equal
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament
Bokour, MCRR 2006; Rosenthal, Health Affairs 2004;
The Leapfrog Compendium; Centers for Medicare & Medicaid Services

21. Desired effect of programs
Quality
“A rising tide lifts all boats.” JFK
Time

22. Evidence for desired effect
Significant
Mixed
None
Fairbrother 1998 *
Hibbard 2003 *
Hickson 1987 *
Kouides 1998 *
Norton 1992
Pourat 2005
Beaulieu 2005
Clark 1995
Casalino 2003
McMenamin 2003
Rosenthal 2005
Grady 1997
Hillman 1998 *
Hillman 1999 *
Shen 2003 6 5 4
*Randomized design
Dudley, AHRQ Technical Paper 2004;
Peterson, Annals Int Med 2006

23. Unknown effect on disparities
Quality ?
Time

24. Quality improvement literature
NEUTRAL
NARROWING
WIDENING
One-size-fits-all
● ESRD patients
● ~40%  in adequate hemodialysis dosing
● White-black disparity persisted
Seghal, JAMA 2003
Culturally sensitive
● Depression
● ~20%  in depression care
● White-minority disparity eliminated
Arean, Medical 2005
One-size-fits all ?
Induces cherry-picking
Widens resource gaps / “rich get richer”
● National QI effort to:
 hemodialysis dose
 anemia management
 nutritional status
● Depression
● Multi-state QI effort to:
 depression care
 depression severity
 functional impairment

25. Quality improvement literature
NEUTRAL
NARROWING
WIDENING
One-size-fits-all
● ESRD patients
● ~40%  in adequate hemodialysis dosing
● White-black disparity persisted
Seghal, JAMA 2003
Culturally sensitive
● Depression
● ~20%  in depression care
● White-minority disparity eliminated
Arean, Medical 2005
One-size-fits all ?
Induces cherry-picking
Widens resource gaps / “rich get richer”
● National QI effort to:
 hemodialysis dose
 anemia management
 nutritional status
● Depression
● Multi-state QI effort to:
 depression care
 depression severity
 functional impairment

26. Quality improvement literature
NEUTRAL
NARROWING
WIDENING
One-size-fits-all
● ESRD patients
● ~40%  in adequate hemodialysis dosing
● White-black disparity persisted
Seghal, JAMA 2003
Culturally sensitive
● Depression
● ~20%  in depression care
● White-minority disparity eliminated
Arean, Medical 2005
One-size-fits all ?
Induces cherry-picking
Widens resource gaps / “rich get richer”
● National QI effort to:
 hemodialysis dose
 anemia management
 nutritional status
● Depression
● Multi-state QI effort to:
 depression care
 depression severity
 functional impairment

27. Quality improvement literature
NEUTRAL
NARROWING
WIDENING
One-size-fits-all
● ESRD patients
● ~40%  in adequate hemodialysis dosing
● White-black disparity persisted
Seghal, JAMA 2003
Culturally sensitive
● Depression
● ~20%  in depression care
● White-minority disparity eliminated
Arean, Medical 2005
One-size-fits all ?
Induces cherry-picking
Widens resource gaps / “rich get richer”
● National QI effort to:
 hemodialysis dose
 anemia management
 nutritional status
● Depression
● Multi-state QI effort to:
 depression care
 depression severity
 functional impairment

28. Quality improvement literature
NEUTRAL
NARROWING
WIDENING
One-size-fits-all
● ESRD patients
● ~40%  in adequate hemodialysis dosing
● White-black disparity persisted
Seghal, JAMA 2003
Culturally sensitive
● Depression
● ~20%  in depression care
● White-minority disparity eliminated
Arean, Medical 2005
One-size-fits all ?
Induces cherry-picking
Widens resource gaps / “rich get richer”
● National QI effort to:
 hemodialysis dose
 anemia management
 nutritional status
● Depression
● Multi-state QI effort to:
 depression care
 depression severity
 functional impairment

29. Quality improvement literature
NEUTRAL
NARROWING
WIDENING
One-size-fits-all
● ESRD patients
● ~40%  in adequate hemodialysis dosing
● White-black disparity persisted
Seghal, JAMA 2003
Culturally sensitive
● Depression
● ~20%  in depression care
● White-minority disparity eliminated
Arean, Medical 2005
One-size-fits all ?
Induces cherry-picking
Widens resource gaps / “rich get richer”
● National QI effort to:
 hemodialysis dose
 anemia management
 nutritional status
● Depression
● Multi-state QI effort to:
 depression care
 depression severity
 functional impairment

30. NEUTRAL
NARROWING
WIDENING

31. NEUTRAL
NARROWING
WIDENING

32. NEUTRAL
NARROWING
WIDENING

33. NEUTRAL
NARROWING
WIDENING

34. Unintended consequences

35. Evidence of desired effect
Significant
Mixed
None
Fairbrother 1998 *
Hibbard 2003 *
Hickson 1987 *
Kouides 1998 *
Norton 1992
Pourat 2005
Beaulieu 2005
Clark 1995
Casalino 2003
McMenamin 2003
Rosenthal 2005
Grady 1997
Hillman 1998 *
Hillman 1999 *
Shen 2003
2 improved documentation only
2 noted cherry-picking
1 rewarded those already doing well
*Randomized design
Dudley, AHRQ Technical Paper 2004;
Peterson, Annals Int Med 2006

36. Evidence of desired effect
Significant
Mixed
None
Fairbrother 1998 *
Hibbard 2003 *
Hickson 1987 *
Kouides 1998 *
Norton 1992
Pourat 2005
Beaulieu 2005
Clark 1995
Casalino 2003
McMenamin 2003
Rosenthal 2005
Grady 1997
Hillman 1998 *
Hillman 1999 *
Shen 2003
2 improved documentation only
2 noted cherry-picking
1 rewarded those already doing well
*Randomized design
Dudley, AHRQ Technical Paper 2004;
Peterson, Annals Int Med 2006

37. Evidence of desired effect
Significant
Mixed
None
Fairbrother 1998 *
Hibbard 2003 *
Hickson 1987 *
Kouides 1998 *
Norton 1992
Pourat 2005
Beaulieu 2005
Clark 1995
Casalino 2003
McMenamin 2003
Rosenthal 2005
Grady 1997
Hillman 1998 *
Hillman 1999 *
Shen 2003
2 improved documentation only
2 noted cherry-picking
1 rewarded those already doing well
*Randomized design
Dudley, AHRQ Technical Paper 2004;
Peterson, Annals Int Med 2006

38. Impact of incentive programs on racial disparities

39. Systematic review of MEDLINE®
536 “hits”  1 empirical study
Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards
1991 New York publicly reported risk-adjusted CABG mortality rates
Compared CABG rates
Hispanics and African Americans vs Whites
Before and after ‘report card’ instituted
NY versus 12 comparison states
1966-March 2006
MeSH and non-MeSH variants of: “performance incentive programs” terms AND “racial disparities” terms 536 hits  only 1 study evaluates the problem empirically
Also evaluated:
Use of alternate therapies (cardiac cath, PTCA) for acute myocardial infarction
Surgeon movement
Patient transfers out-of-state
Werner, Circulation 2005

40. Systematic review of MEDLINE®
536 “hits”  1 empirical study
Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards
1991 New York publicly reported risk-adjusted CABG mortality rates
Compared CABG rates
Hispanics and African Americans vs Whites
Before and after ‘report card’ instituted
NY versus 12 comparison states
1966-March 2006
MeSH and non-MeSH variants of: “performance incentive programs” terms AND “racial disparities” terms 536 hits  only 1 study evaluates the problem empirically
Also evaluated:
Use of alternate therapies (cardiac cath, PTCA) for acute myocardial infarction
Surgeon movement
Patient transfers out-of-state
Werner, Circulation 2005

41. Systematic review of MEDLINE®
536 “hits”  1 empirical study
Racial profiling: unintended consequences of coronary bypass graft (CABG) report cards
1991 New York publicly reported risk-adjusted CABG mortality rates
Compared CABG rates
Hispanics and African Americans vs Whites
Before and after ‘report card’ instituted
NY versus 12 comparison states
1966-March 2006
MeSH and non-MeSH variants of: “performance incentive programs” terms AND “racial disparities” terms 536 hits  only 1 study evaluates the problem empirically
Also evaluated:
Use of alternate therapies (cardiac cath, PTCA) for acute myocardial infarction
Surgeon movement
Patient transfers out-of-state
Werner, Circulation 2005

42. 1991 New York “CABG Report Cards” Werner, Circulation 2005

43. 1991 New York “CABG Report Cards” Werner, Circulation 2005
0.7

44. 1991 New York “CABG Report Cards” Werner, Circulation 2005
3.2
0.7

45. 1991 New York “CABG Report Cards” Werner, Circulation 2005
3.2
0.7
2.7

46. 1991 New York “CABG Report Cards” Werner, Circulation 2005
3.2
5.0
0.7
2.7

47. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not necessarily have the needs of racial & ethnic groups or disparities in mind
Have features that may contribute to widening disparities

48. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not necessarily have the needs of racial & ethnic groups or disparities in mind
Have features that may contribute to widening disparities

49. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not necessarily have the needs of racial & ethnic groups or disparities in mind
Have features that may contribute to widening disparities

50. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not necessarily have the needs of racial & ethnic groups or disparities in mind
Have features that may contribute to widening disparities

51. Leader Perspectives

52. Leader Perspectives NARROWING ? Measuring race and/or ethnicity
? Identifies minority sub-groups
WIDENING
? Induces cherry-picking
? Widen resource gaps / “rich get richer”

53. Leader Perspectives NARROWING ? Measuring race and/or ethnicity
? Identifies minority sub-groups
WIDENING
? Induces cherry-picking
? Widen resource gaps / “rich get richer”

54. Leader Perspectives Leaders from: 5 Nationally prominent PIPs
4 State Medicaid PIPs
6 Commercial health plan PIPs 15

55. Does/will your PIP: 4 / 15 Measure race/ethnicity
NARROW DISPARITIES
Leaders
Responding
“YES”
Does/will your PIP:
Measure race/ethnicity
Identify sub-groups in need of more tailored programs
4 / 15

56. Does/will your PIP: 8 / 15 4 / 15 Measure race/ethnicity
NARROW DISPARITIES
Leaders
Responding
“YES”
Does/will your PIP:
Measure race/ethnicity
Identify sub-groups in need of more tailored programs
8 / 15
4 / 15

57. Does/will your PIP: 8 / 15 4 / 15 Measure race/ethnicity
NARROW DISPARITIES
Leaders
Responding
“YES”
Does/will your PIP:
Measure race/ethnicity
Identify sub-groups in need of more tailored programs
8 / 15
4 / 15

58. Does/will your PIP: 6 / 15 * Induce “cherry-picking”
WIDEN DISPARITIES
Leaders
Responding
“NO”
Does/will your PIP:
Induce “cherry-picking”
Widen resource gaps / allow the “rich to get richer” while the “poor get poorer”
6 / 15 *

59. Does/will your PIP: 6 / 15 * 6 / 15 * Induce “cherry-picking”
WIDEN DISPARITIES
Leaders
Responding
“NO”
Does/will your PIP:
Induce “cherry-picking”
Widen resource gaps / allow the “rich to get richer” while the “poor get poorer”
6 / 15 *
6 / 15 *
*mainly State Medicaid PIPs

60. Does/will your PIP: 6 / 15 * 6 / 15 * Induce “cherry-picking”
WIDEN DISPARITIES
Leaders
Responding
“NO”
Does/will your PIP:
Induce “cherry-picking”
Widen resource gaps / allow the “rich to get richer” while the “poor get poorer”
6 / 15 *
6 / 15 *
*mainly State Medicaid PIPs

61. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not necessarily have the needs of racial & ethnic groups or disparities in mind
Have features that may contribute to widening disparities

62. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not have disparities in mind
Have features that may contribute to widening disparities

63. Summary Literature: Programs as currently designed:
PIPs may not improve quality
Quality improvement does not necessarily narrow disparities
PIPs may widen racial/ethnic disparities
Programs as currently designed:
Do not have disparities in mind
Have features that may widen disparities

64. Recommendations

65. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament

66. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
#3 Decide “individual” versus “system”
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament

67. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament

68. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
#3 Decide “individual” versus “system”
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament

69. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
#3 Decide “individual” versus “system”
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
#4 Make stratified comparisons
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament

70. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
#3 Decide “individual” versus “system”
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
#4 Make stratified comparisons
#5 Explore “disparity” measures
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
● Risk adjustment
● Achievement
● Improvement
● Tournament

71. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
#3 Decide “individual” versus “system”
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
#4 Make stratified comparisons
#5 Explore “disparity” measures
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
#6 Consider risk adjustment
#7 Reward improvement
● Achievement
● Improvement
● Tournament

72. Recommendations Context: Payors: Payees: Incentivized Measures:
● Fee-for-service
● Capitation
● Commercial
● Un/Underinsured
Context:
Payors:
Payees:
Incentivized Measures:
Incentive Triggers:
#1 Understand the patient/provider mix
#2 Measure race and/or ethnicity
#3 Decide “individual” versus “system”
● Federal government
● State government
● Commercial health plans
● Private stakeholder coalitions
● Individual doctors ● Practices/groups ● Hospitals
#4 Make stratified comparisons
#5 Explore “disparity” measures
● Clinical process/outcome
● Clinical access
● Patient satisfaction
● Use of formulary
● Administrative efficiency
#6 Consider risk adjustment
#7 Reward improvement
● Achievement
● Improvement
● Tournament

73. 5841 S. Maryland Avenue – MC 6082, Chicago IL 60637
Alyna T. Chien, MD MS
5841 S. Maryland Avenue – MC 6082, Chicago IL 60637